GEMNet: Management of Suspected Scaphoid Fractures in the ...

Guidelines in Emergency Medicine Network - GEMNet

Guideline for the

Management of Suspected

Scaphoid Fractures in the

Emergency Department

The College of Emergency Medicine

September

2013

#6

GEMNet: Management of Suspected Scaphoid Fractures in the ED (September 2013) 2


About this guideline

Running title: GEMNet guideline: Management of Suspected

Scaphoid Fractures in the Emergency Department

Version Control: First published Sept 2013

Authors: Emma Machin

Julian Blackham

Jonathan Benger

Main affiliation: Emergency Department, Bristol Royal Infirmary,

Upper Maudlin Street, Bristol, BS2 8HW

Corresponding author and address: Professor Jonathan Benger, Emergency

Department, Bristol Royal Infirmary, Upper Maudlin

Street, Bristol, BS2 8HW

E-mail: [email protected]

Published September 2013

Review September 2018

mailto:[email protected]


Contents

1. Executive summary p5

2. Introduction p6

3. Topic background p6

4. Scope p8

5. Methodology p8

6. Summary of recommendations p10

7. Detailed findings p12

7.1 Clinical examination p12

7.2 Imaging p14

7.3 Immobilisation p23

7.4 Follow up p24

7.5 Scaphoid fractures in children p24

8. Evidence-based flowchart p25

References p26


1. Executive summary

• The Guidelines in Emergency Medicine Network (GEMNet) exists to promote best

medical practice in a range of conditions presenting to Emergency Departments

(EDs) in the UK.

• This guideline presents a summary of the best available evidence to guide the

management of adult patients who present to the ED with a suspected scaphoid

fracture.

• The guideline has been developed following discussion amongst Emergency

Physicians to decide which topics would benefit from the development of clinical

guidelines.

• The guideline is intended for use in the ED by Emergency Physicians and is based on a

review of the best available evidence at the time of writing.

• There is no one examination finding or combination of examination findings that can

reliably exclude a scaphoid fracture. However it would be reasonable to consider this

possibility if the patient has sustained trauma compatible with scaphoid fracture and

has anatomical snuffbox or scaphoid tubercle tenderness. Such patients should

usually undergo imaging.

• Plain radiographs remain a useful first line imaging test for scaphoid fracture, however

they are insufficiently sensitive to exclude a fracture. Repeat imaging between 2 and

6 weeks increases the sensitivity, but is still not high enough to exclude a fracture.

• On the basis of currently available evidence, dual energy X-Ray absorptiometry,

macroradiography, ultrasound and intrasound vibration cannot be recommended as

useful imaging tests for a suspected scaphoid fracture.

• Bone scanning has a very high sensitivity; however it also produces a number of false

positives when compared with delayed plain radiographs. There have been few

studies of CT, but those performed demonstrate a high sensitivity for scaphoid fracture.

• MRI for patients with ongoing clinical suspicion of scaphoid fracture despite normal

initial radiographs has a very high sensitivity for detecting scaphoid fracture and other

injuries to the wrist, and is the second-line investigation of choice.

• There are no studies comparing wrist splints with or without thumb extensions to a

plaster cast for the definitive management of scaphoid fractures. Based on the

available evidence there is no benefit of a scaphoid cast over a standard “Colles”

cast.

• There is no guidance in the published literature on follow up per se. The period of

follow up is dependent on the chosen imaging modality, since once a fracture has

been excluded further follow up is not required.

• These recommendations are summarised in a clinical decision support guideline that

has been presented as a simple algorithm.

• The intention is for every GEMNet guideline to be updated and reviewed as further

evidence becomes available. The formal revision date has been set at 5 years from

publication, though the guideline is subject to continuous informal review.


2. Introduction

2.1 Responsibility for development

This document has been developed in response to a perceived need to improve and

standardise clinical care in patients with a suspected fracture of the scaphoid bone. The

intention is to distil the best available evidence into practical advice for clinicians working

in the Emergency Department. The information is presented in the form of clinical decision

support guidelines, readily available for use in the ED.

Abbreviations used in this guideline:

ASB - Anatomic snuff box

CT – Computed tomography

ED – Emergency Department

LC – Longitudinal compression

MRI – Magnetic resonance imaging

SC – Scaphoid compression

ST - Scaphoid tubercle

3. Topic background

Scaphoid fractures are the commonest fracture of the carpal bones, comprising almost

90% of carpal fractures. They are most common in men aged between 15 and 30 years.

Middle third Scaphoid fractures usually result from extreme dorsiflexion of the wrist with

pressure over the radial side of the palm – most commonly due to a fall on an

outstretched hand. Scaphoid fractures can also be caused by a direct blow to the palm

of the hand; historically this was a “crank handle” injury, but it can also be caused by

holding a car steering wheel during a motor vehicle collision.

Generations of medical students have been told that tenderness in the anatomical snuff

box is the cardinal sign of a scaphoid fracture, and that missed scaphoid fractures are

common. The cutaneous branch of the radial nerve runs directly over the anatomical

snuff box, which means that discomfort on firm palpation of this area is common even in

the absence of injury.[1]

The published incidence of false negative initial radiographs is between 5 and 48%.[2]

Early diagnosis is commonly held to be necessary in order to avoid complications such as

non-union, pseudoarthrosis and avascular necrosis. That said, as long ago as 1969

McLaughlin and colleagues noted that fractures of the scaphoid that were not visible on


the initial radiographs were ‘class A fractures’: undisplaced fractures that are little more

than a split in the articular cartilage.[3] They stated that ‘it was abundantly clear that,

barring a reinjury, the fractures in this group would heal under almost any circumstance’.

The incidence of delayed union increases from 9% in patients where treatment is instituted

within days of fracture to 36% if treatment is delayed beyond 4 weeks. Similarly, the non-

union rate rises from 5% to 45%.[4]

A number of authors have questioned the diagnosis of ‘clinically fractured’ scaphoid.

Duncan et al. undertook a study of patients with suspected or proven scaphoid fractures

over one year in a single hospital.[5] Of the 156 patients, 42 were initially felt to have

scaphoid fractures, and 108 to have a clinical scaphoid fracture by the “casualty officer”.

They were unable to demonstrate a case of a scaphoid fracture becoming visible

radiologically after a period of observation. Leslie noted that of 222 fresh scaphoid

fractures, 98% were visible on initial radiographs, but 3% of these were missed by “casualty

officers”.[6] The remaining 2% were not visible until 2 weeks, however these were

incomplete fractures. As noted above, McLaughlin felt that incomplete fractures of this

type were stable fractures that required no immobilization.

There is great variation between hospitals in the initial management of suspected

scaphoid fractures, even amongst neighbouring hospitals.[7] In an international study of

hospital management of suspected scaphoid fractures, there was no agreement on initial

imaging, follow up period or the type of repeat imaging for ongoing clinical suspicion. The

most common second line investigation was MRI (31/105).[8]

The immobilisation of a suspected scaphoid fracture entails significant inconvenience for

patents; in many cases leaving them unable to work for prolonged periods of time (an

average of 21 days in one study).[5]

Recent Royal College of Radiology guidelines recommend plain radiology followed by CT,

MRI or nuclear medicine, but with MRI as the recommended form of secondary

imaging.[9] The current American College of Radiology guidance recommends repeat

plain radiographs at 14 days or MRI if the original radiographs are normal, with CT as a an

alternative option if MRI contra-indicated.[10]

Dorsay and colleagues reviewed the published literature as part of a cost effectiveness

study to find the positive predictive value of clinical examination.[11] They found it ranged

from 13-69%, with a weighted average of 21%. This means that four out of five patients with

a clinically suspected Scaphoid fracture turn out not to have one. They went on to look at

the negative predictive value of normal initial radiographs and noted that the range was

50-80%, with a weighted average of 74%.


4. Scope

This guideline is intended for the management of patients aged over 8 years presenting to

the Emergency Department with suspected scaphoid fracture. Scaphoid fractures are

very rare in children under 8 years of age; alternative diagnoses should therefore be

considered in this patient group.

5. Methodology

MEDLINE 1966-05/11, EMBASE 1980-05/11, CINHAL 1981-05/11 and the Cochrane Library

were searched using the strategies described below to answer a number of “three part”

questions:

5.1 Clinical examination

In a [patient with suspected scaphoid fracture] which [clinical test] is most effective

in [diagnosing a scaphoid fracture] [12]

[(SCAPHOID BONE OR scaphoid.ti.ab) AND (FRACTURES, BONE/di) AND (PHYSICAL

EXAMINATION OR (clinical ADJ test).ti.ab) OR examin$.ti)]

5.2 Imaging

In a [patient with suspected scaphoid fracture] which [imaging strategy] is most

effective in [achieving the correct diagnosis]

[(SCAPHOID BONE OR scaphoid.ti.ab) AND (FRACTURES, BONE/di) AND

(DIAGNOSTIC IMAGING/ OR MAGNETIC RESONANCE IMAGING/ OR RADIONUCLIDE

IMAGING/ OR TECHNETIUM TC 99M MEDRONATE/ OR TECHNETIUM/ OR X-RAYS/ OR

ultrasound.ti,ab OR mri.ti,ab OR (magnet$ ADJ resonan$).ti,ab OR x-ray$.ti,ab OR

(bone AND scan).ti,ab OR scint$.ti,ab)]

5.3 Immobilisation

In a [patient with a clinically suspected scaphoid fracture] is [wrist immobilisation in

a splint] better than [wrist immobilisation in a cast] for [reducing complications from

occult fractures]

[(SCAPHOID BONE OR scaphoid.ti.ab)] AND [(CASTS, SURGICAL/ OR CALCIUM

SULFATE/ OR SPLINTS/) OR (plaster AND of AND paris).ti,ab OR splint$.ti,ab OR

IMMOBILIZATION/ OR immobilisation.ti,ab OR immobilization.ti,ab OR cast$.ti,ab]

AND [FRACTURES, BONE/]


5.3 Follow up

In a [patient with a clinically suspected scaphoid fracture] is [clinical follow up] or

[further imaging] best for [excluding occult fractures]

The duration of follow up was considered in the imaging section. It was noted that

the sensitivity and timing of clinical and radiological examination determines the

duration of follow up required.

Cochrane reviews

There was one relevant Cochrane review: “Diagnosing suspected scaphoid

fractures: a systematic review and meta-analysis”.[2]

Levels of evidence and grading of recommendations

Studies included in this guideline were graded for their level of evidence according to

accepted definitions.[13]

In summary:

Level 1 evidence is derived from well-designed randomised controlled trials (RCTs),

Level 2 evidence is derived from large cohort studies or poorly designed RCTs,

Level 3 evidence is derived from small cohort studies or case-control studies, and

Level 4 evidence is derived from experimental studies, case series or case studies.

The suffix ‘a’ implies that evidence at this level is from a systematic review or meta-

analysis, whereas the suffix ‘b’ implies that the evidence is from original research.

The recommendations made have been graded according to the level of evidence upon

which they are based:

Grade A: Based upon multiple level 1a or 1b papers.

Grade B: Based upon individual level 1a or 1b papers, or multiple level 2a or 2b papers.

Grade C: Based upon individual level 2a or 2b papers, or multiple level 3a or 3b papers.

Grade D: Based upon individual level 3a or 3b papers, or level 4 papers.

Grade E: Based upon consensus guidelines or studies of expert opinion.


6. Summary of recommendations


There is no one examination or combination of examinations that can reliably exclude a

scaphoid fracture. This is based on a number of small level 3 studies which limits the

reliability of the conclusions that can be drawn. The highest probability of fracture is in

patients with ASB and ST tenderness combined with pain on LC of the thumb (sensitivity

100%; specificity 74%). ASB or ST tenderness also has a reasonable specificity and

sensitivity.

It would be reasonable to consider the possibility of a scaphoid fracture if the patient has

ASB or ST tenderness as this will pick up patients in both the above groups. These patients

should undergo imaging. [Grade C]

6.2 Imaging

A problem with all published studies is the lack of a “gold standard” imaging modality

against which reliable comparisons can be made. Plain radiographs are a useful first line

imaging technique for scaphoid fracture; however they are insufficiently sensitive to

exclude a fracture. Repeat imaging at between 2 and 6 weeks increases the sensitivity,

but is still not high enough to exclude fracture.

Dual energy X-Ray absorptiometry and macroradiography are not sensitive or specific

enough to have a role in excluding scaphoid fractures. There have been a number of

small studies looking at the role of ultrasound and intrasound vibration in the diagnosis of

scaphoid fractures. There is great variation in the sensitivity and specificity of ultrasound,

and this modality cannot be recommended on the basis of currently available evidence.

[Grade C]

Bone scanning has a very high sensitivity (100% in most studies), however it produces a

number of false positives when compared with delayed plain radiographs. It also requires

intravenous radioisotope and multiple images over a 3 hour period which is inconvenient

for patients and represents a significant workload for radiology departments. [Grade C]

There have been few studies of CT, but those performed demonstrate a high sensitivity for

scaphoid fracture. [Grade C]

In comparison studies MRI performs similarly to CT and bone scan. MRI for patients with an

ongoing clinical suspicion of scaphoid fracture despite normal initial radiographs has a

very high sensitivity for detecting scaphoid fracture and other injuries to the wrist, and is

the second-line imaging investigation of choice. [Grade C]


6.3 Immobilisation

There are no studies comparing wrist splints with or without thumb extensions to a plaster

cast for the definitive management of scaphoid fractures. Based on the available

evidence:

• There is no benefit of a scaphoid cast over a standard “Colles” cast. [Grade C]

• Immobilising the wrist in up to 20 degrees extension is better than having the

wrist immobilised in flexion [Grade D]

• There may be some benefit to immobilising a scaphoid fracture in an above

elbow cast, but the two studies in this area do not agree.

6.4 Follow up

There is no useful guidance in the literature regarding the duration of patient follow up.

The period of follow up is dependent on the chosen imaging modality, since once a

fracture has been excluded (normal MRI, CT or bone scan) further follow up is not

required.


7. Detailed findings

1. Clinical Examination

The search strategy produced 21 unique results

2. Imaging


3. Immobilisation


4. Follow up

The search strategy produced no useful results

5. Scaphoid Fractures in Children


Clinical suspicion of a fractured scaphoid leads to many patients being immobilised

unnecessarily,[14] with the incidence of occult fracture being reported as low as 1.3% and

a final diagnosis of soft tissue injury being made in 88.8% of patients. Knowledge of surface

anatomy of the carpal bones is often poor.[15]

Clinical examination can be useful, but any proposed clinical test should be easy to teach

and apply. Table 1, below, summarises 9 studies looking at commonly used clinical

examination findings. The sensitivity of clinical examination tests are usually high, but the

corresponding specificity poor, limiting their use in clinical practice.

Table 1: Clinical examination findings

Study

Patient group

Incidence (and

Gold standard

used)

ASB

tenderness ST tenderness

Axial loading

of thumb*

Other

examination

findings and

combinations

Freeland [16]

246 patients

presenting

over a 10

month period

with possible

scaphoid

fracture

30 patients

eventually

shown to have

a fracture

Sensitivity

= 90%

Specificity

= 40%

Sensitivity

= 87%

Specificity =

57%

- -

Parvizi et al

[17]

215 patients

presenting

within 24 hours

of injury with a

suspected

scaphoid

fracture.

56 patients had

proven

scaphoid

fractures on

initial or repeat

plain

radiographs or

radioisotope

bone scan

Sensitivity

=100%

Specificity

= 19%

Sensitivity

=100%

Specificity =

30%

Sensitivity

=100%

Specificity

= 48%

ASB, ST and LC

Sensitivity

=100%

Specificity =

74%

Esberger [18] 99 patients

with suspected

Scaphoid

fracture,

Initial x-rays

positive = 34

patients. 10

further fractures

found on

repeat x-ray or

bone scan at 2

weeks

- - Sensitivity

= 70%

Specificity

= 22%

-


Waizenegger

et al [19]

64 patients

with suspected

scaphoid

fracture

presenting

within 3 days

of injury

52 included

patients of

whom 23 had

confirmed

scaphoid

fractures and 29

in whom

scintigraphy

excluded a

scaphoid

fracture

Day 1/Day 14

Sensitivity

= 87%/65%

Specificity

= 38%/41%

- Day 1/Day 14

Sensitivity

= 48%/9%

Specificity

= 52%/76%

Pronation/ulnar

deviation –

Day1/Day14

Sensitivity

= 82%/57%

Specificity

= 17%/45%

Grover [20] 221 patients

with suspected

scaphoid

fracture

presenting

over a 6

month period

29 patients had

proven

fractures, plain

X-rays repeated

10 days if initial

films were

normal

Sensitivity

= 100%

Specificity

= 29%

Sensitivity

= 83%

Specificity

= 51%

Sensitivity

= 100%

Specificity

= 80%

Wrist diameter

- significantly

higher in

patients with a

fracture

(p<0.05) but no

cut-off value

given

Rhemrev et al

[21]

78 patients

with suspected

clinically

scaphoid

fracture

presenting

within 48 hours

of injury and

normal initial

plain

radiography

13 patients had

definite

scaphoid

fractures

following MRI

and bone

scintigraphy

assessment

- - - Supination

strength <10%

of

contralateral

side

Sensitivity =

85% Specificity

= 59%

Extension <50%

of

contralateral

side

Sensitivity =

85% Specificity

= 59%

Unay et al [22] 187 patients

with a

suspected

scaphoid

fracture

presenting to a

single hospital

over a 1-year

period.

Initial x-rays

positive = 89. Of

remaining 98

patients, 67 had

MRI, which

showed 12

additional

scaphoid

fractures.

- - Sensitivity

= 71%

Specificity

= 35%

Pain on

thumb/index

pinch

Sensitivity =

73%

Specificity =

75%

Pain during

pronation

Sensitivity =

79%

Specificity =

58%

Wilson et al

[23]

111 patients

with clinical

scaphoid injury

but normal

initial

radiographs

29 patients had

scaphoid

fractures

confirmed on

bone

scintigraphy

- - Sensitivity

= 70%

Specificity

= 22%

-

Evenski et al

[24]

104 children

referred to

orthopedics

with high

clinical

suspicion of

scaphoid

fracture but

normal initial X-

ray

31children had

radiographically

evident

scaphoid

fracture on

follow up x-ray

Sensitivity

= 100%

Specificity

= 9%

- - Volar scaphoid

tenderness OR

5.50

Pain with radial

deviation

OR 9.75

Pain with wrist

active range

of movement

OR 5.51

* Axial loading of thumb includes tests described as Scaphoid compression or longitudinal thumb compression or thumb

telescoping or thumb compression.


7.2 Imaging

Macroradiography

Only 2 studies on macroradiography were identified, these are summarised in table 2. On

the basis of the available evidence macroradiography cannot be recommended as a

useful diagnostic test in clinically suspected scaphoid fracture.

Table 2: Macroradiography

Study

Patient group Key Results

Gaebler et al

[25]

60 patients with suspected scaphoid

fractures and normal initial radiography

underwent macroradiography and MRI

(8 confirmed scaphoid fractures)

Sensitivity = 50%, Specificity =

100%, Positive Predictive

Value = 100%, Negative

Predictive Value = 92.8%

Kukla et al [26] 25 patients with suspected scaphoid

fractures and normal initial radiography

underwent macroradiolgraphy and MRI

(4 confirmed scaphoid fractures)

Correctly identified 2 of 4

scaphoid fractures and 4 of

8 bony lesions of the

scaphoid.

Dual Energy X-Ray Absorptiometry (DXA) scanning

1 study, summarised in table 3, suggested that DXA scanning is insufficiently sensitive and

specific to be clinically useful.

Table 3: Dual Energy X-Ray Absorptiometry (DXA) scanning

Study


Stephen et al

[27]

10 patients with known scaphoid

fractures were compared to 10 controls

with DXA scans at day 3 post injury



Value = 55.5%, Negative


Sonography and Intrasound Vibration

There is great variation in the sensitivity and specificity of ultrasound, with sensitivity ranging

from 33.3% to 100% in the 5 studies shown in table 4.

Shenouda and England [30] also found timing to be important. In patients with definite

fractures where the ultrasound test was initially positive it became negative after the

second or third visits.

Ultrasound cannot be recommended on the basis of currently available evidence. At

present there is insufficient evidence to support the use of intrasound vibration in the

diagnosis of scaphoid fracture.


Table 4: Sonography and Intrasound Vibration

Study

Patient Group Key Results

Hauger et al [28] 54 patients with clinical scaphoid

fracture and normal radiographs

underwent ultrasound examination

within 7 days of injury, followed up at

2 weeks with conventional

radiography and MRI, CT or bone

scanning


98%, Positive Predictive Value

= 83%, Negative Predictive

Value = 100% (Accuracy =

98%)

Senall et al [29] 18 patients with clinical scaphoid

fracture but normal initial radiographs

who underwent ultrasound of the

scaphoid were then followed up with

plain radiographs (9 confirmed

fractures)




Value = 80%

Shenouda and

England [30]


fractures – ultrasound assessment

considered positive if pain, tingling or

burning on affected side (43

confirmed fractures)

Sensitivity = 90.7%, Specificity =

96.7%, Positive Predictive



(Accuracy = 93%)

DaCruz et al [31] 111 patients with clinical scaphoid

fracture and negative initial radiology

– ultrasound within a week of injury

and re-x-rayed at 2-3 weeks (6

confirmed fractures)

Sensitivity = 33.3%, Specificity =

62.8%, Positive Predictive



Finkenberg et al

[32]

50 patients with clinical scaphoid

fracture and negative initial imaging

underwent intrasound vibratory

testing prior to bone scan/delayed X-

ray examination (6 confirmed

fractures)




Value = 100%

A further 36 patients (excluded

from study as confirmed

fracture on initial radiography)

all had positive vibratory tests.

Scintigraphy (Bone Scan)

Bone scintigraphy has excellent sensitivity for the detection of scaphoid fracture, but

generates a number of false positive results (Table 5). Technical difficulties and the

duration and cost of the test limit its usefulness in clinical practice.


Table 5 Scintigraphy/Bone scanning

Study


Stordahl et al

[33]

28 patients with clinically

suspected scaphoid fracture

and normal initial radiography

who underwent bone scanning

at 2 weeks post injury and

repeat x-rays at 2 and 6 weeks.

Sensitivity = 100%, Specificity = 57.89%,

Positive Predictive Value = 52.9%,

Negative Predictive Value = 100%

N.B.: 2 patients who were excluded as

had confirmed scaphoid fractures on

initial imaging both had positive bone

scans.

Waizenegger

et al [34]

84 patients with clinically

suspected scaphoid fracture

and normal initial radiology who

underwent bone scanning and

repeat radiography +/- CT

scanning (7 confirmed scaphoid

fractures)

Sensitivity = 100%, Specificity = 85%,

Positive Predictive Value = 50%,


N.B.: 25 patients had increased uptake

in areas of the wrist other than the

scaphoid

Akdemir et al

[35]

32 patients with suspected

carpel injury and normal

radiology underwent bone

scintigraphy at 2 weeks post

injury. (8 confirmed scaphoid

fractures)




N.B.: 12 patients had fractures of

bones other than the scaphoid, and

all had positive bone scans

Young et al

[36]


scaphoid fracture and normal

initial radiology who had bone

scanning at 10-14 days post

injury and repeat radiology at 3

weeks (3 confirmed fractures)




N.B.: 2 patients had ‘mildly positive’

bone scans which were treated as

‘normal’ with under 3 weeks

immobilization – neither patient had a

confirmed fracture.

Jorgensen et

al [37]


scaphoid fracture who had

plain radiographs on the day of

presentation, x-ray and bone

scan on day 10 and x-ray on

day 20 (22 confirmed fractures)

Sensitivity = 100%, Specificity = 37.04%,

Positive Predictive Value = 52.78%,


N.B.: 4 patients had uninterpretable

bone scans due to wet plasters and 10

of the positive bone scan patients had

fractures of bones other than the

scaphoid.

Wilson et al

[23]


scaphoid injury but normal initial

radiology underwent bone

scanning. The first 42 patients

were re-x-rayed at 10 days.

Bone scanning used as rule out test –

those with negative bone scans had

immobilization removed and no

missed fractures were reported. 29

patients had bone scans consistent

with scaphoid fracture – 2 of whom

had positive x-rays at day 10 –

however only 42 of the 111 patients

underwent x-rays at day 10.

Bayer et al

[38]


scaphoid fracture and initially

normal radiographs had bone

scanning at 14 days post injury

(8 confirmed scaphoid

fractures)




N.B.: 10 patients with positive bone

scans had wrist fractures affecting

bones other than the scaphoid


CT Scanning

2 studies, summarised in table 6, looked specifically at the use of CT scanning. Further

papers considered CT scanning in comparison to other modalities and these are discussed

later.

Table 6: CT scanning

Study


Temple et al [39] CT and plain film images

were compared in 11

cadaver specimens with

iatrogenic fractures.

CT:

Sensitivity for detecting fracture =100%,

sensitivity for detecting if fracture

displaced >1mm =50%, specificity for

detecting if fracture displaced >1mm

=89%

Plain film:

Sensitivity for detecting fracture =99%,

Specificity for detecting if fracture

displaced >1mm =84%

Nguyen et al [40] 118 patients with clinical

scaphoid fractures and

normal or non-conclusive

initial x-rays underwent CT

scanning (26 fractures

were identified)

3 scaphoid fractures identified by CT in the

16 patients with suspicious initial

radiography

23 scaphoid fractures identified by CT in

the 102 patients with normal films

MRI

Table 7 summarises the studies looking at MRI. The sensitivity for detecting scaphoid

fractures was excellent (typically 100%) while also being able to give diagnostic

information on non-scaphoid injuries both bony and ligamentous.


Table 7: MRI scanning

Study


Brydie & Raby

[41]

195 patients with clinically suspected

scaphoid fractures and normal initial

x-rays underwent MRI. 2 patients were

excluded due to movement artifact.

(37 scaphoid fractures were

identified)

37 scaphoid fractures

demonstrated

37 non-scaphoid fractures (28

distal radial)

20 bone bruises

99 normal examinations

180 (92%) of patients had

management altered as a

result of MRI findings.

Bretlau et al [42] 47 patients with clinically suspected


x-rays underwent MRI between 4 and

11 days post presentation and at 8

weeks if positive for fracture. 5

patients were excluded. (9 scaphoid

fractures were identified)

All 9 scaphoid fractures

detected on initial MRI

(sensitivity =100%) plus 9 other

carpal/distal radial fractures

Lepisto et al

[43]

18 patients with clinically suspected

scaphoid fractures underwent MRI.

(11 acute fractures were identified)

11 acute fractures

demonstrated and also

identified ligamentous injuries

2 fractures detected on plain

film were not apparent on MRI

but proved to be old

Kukla et al [26] 25 patients with clinically suspected

scaphoid fracture and normal initial

plain films underwent MRI within 7

days of injury with treating clinicians

blinded to MRI results (9 fractures

identified)

4 scaphoid body fractures and

5 other bony lesions (e.g.

avulsion fractures) of scaphoid

identified. Sensitivity =100%

Kumar et al [44] 22 patients with clinical scaphoid

fractures and normal initial plain films

had MRI imaging within 24 hours of

presentation with review and repeat

plain films or MRI at 10-14 days. (6

scaphoid fractures were identified on

initial MRI)


100%

Hunter et al [45] 36 patients with clinically suspected

scaphoid fracture and normal initial

plain films underwent MRI and repeat

plain films at 2 weeks (13 scaphoid

fractures identified)

10 of the 13 scaphoid fractures

became visible on plain film.

Sensitivity =100%

Khalid et al [46] 611 patients with clinically suspected


x-rays underwent MRI within 2 weeks

of injury

269 patients had normal scans

272 patients had acute bony

injuries (including scaphoid

fractures)

23 patients had acute soft tissue

injuries

47 scans demonstrated

incidental pathology


Comparing Bone Scan with MRI

Two studies compared scintigraphy (bone scanning) with MRI and are described in table

8.

Table 8: Bone scanning versus MRI scanning

Study


Thorpe et al [47] Prospective study comparing bone

scan and MRI in 62 patients (3 of whom

were excluded due to inability to

tolerate MRI/degraded images) with

suspected scaphoid fracture and

normal initial radiographs. 4 scaphoid

fractures were identified.

Bone Scan

Sensitivity = 100%, Specificity

= 94.5%, Positive Predictive


Predictive Value = 100%

MRI


= 98.18%, Positive Predictive



Beeres et al [48] Study comparing bone scan and MRI in


fracture and normal initial radiographs

with plain radiographs and examination

at 6 weeks used as gold standard

where there was disagreement

between MRI and bone scan. 20

scaphoid fractures were identified.

Bone Scan


= 90%, Positive Predictive



MRI





Comparing CT and Bone Scan

Only 1 study compared CT against bone scanning, the details of which are given in table

9.

Table 9: CT versus Bone Scan

Study


Breederveld et al [49] Prospective study comparing

CT and bone scan with follow

up CT at 6 weeks and clinical

follow up at 8-14 months in 29

patients with suspected


initial radiographs. 9 scaphoid

fractures identified.

Bone Scan

Sensitivity = 78 %, Specificity =

90%, Positive Predictive Value =

78%, Negative Predictive Value =

90%

CT


100%, Positive Predictive Value =

100%, Negative Predictive Value

= 100%


Comparing MRI and CT

Table 10 summarises the 2 studies comparing MRI and CT.

Table 10: CT versus MRI

Study


Memarsadeghi

et al [50]

Prospective study comparing CT

and MRI against gold standard

of plain radiographs at 6 weeks

in 29 patients with suspected


initial radiography –

differentiated between cortical

fractures (8 fractures) and

trabecular fractures (3 fractures)

MRI – All scaphoid fractures


Accuracy = 100%,

MRI – Cortical scaphoid fractures


Accuracy = 55%,

CT – All scaphoid fractures


Accuracy = 89%,

CT – Cortical scaphoid fractures

Sensitivity = 100%, Specificity = 100

%, Accuracy = 100%,

Mallee, W., et al.

2011

Prospective study comparing CT

and MRI against gold standard

of plain radiographs at 6 weeks

in 40 patients with suspected


initial radiography. 6 scaphoid

fractures identified (5 on plain

films, 1 not visible on x-ray but

seen on CT and MRI) with 5

patients lost to follow up and 1

excluded due to inadequate

imaging.

MRI – scaphoid fractures only

Sensitivity = 67 %, Specificity = 89%,

Accuracy = 85%,

CT – scaphoid fractures only


Accuracy = 91%,

The results of the Mallee study are significantly worse than all others looking at CT and MRI.

The authors excluded all fractures visible on initial imaging, and considered a focal area of

bone oedema on MRI as diagnostic of a fracture. If the MRI criteria had been changed to

require a cortical abnormality to be visible, then it would have found 4 fractures (instead

of 7), with one false positive result (instead of 3) and three false-negative results (instead of

2). This would have given a sensitivity of 50%, specificity of 96% and accuracy of 88%.

One difficulty is the lack of a definition as to what constitutes a scaphoid fracture. MRI

findings may be a bone bruise, CT findings may be a vascular channel, and 6 week plain

radiography may not be a definitive gold standard.

Cost effectiveness studies

There have been a number of cost effectiveness studies that demonstrate that one mode

of imaging is more cost effective than another. These are shown in Table 11. However

there is great variation in the calculated costs of different types of imaging and follow up,

which makes interpretation of these data difficult. Furthermore the loss of income and

personal inconvenience associated with being unnecessarily immobilized in a cast or splint


is difficult to quantify, and will vary greatly between individuals.

Table 11: Cost effectiveness studies comparing different management strategies in

suspected Scaphoid fracture.

Study MRI Cost X-ray cost Clinic cost Bone scan

cost

Plaster cast

cost

Gooding et

al [65]

NZ$300 NZ$60 NZ$77 Not stated NZ$125

Brooks et al

[64]

AU$475 AU$28 1st AU$119

(subsequent

AU$60)

AU$295 Not stated

Saxena et al

[63]

£120 £22 £40 £70 £25

Hansen et al

[62]

€330 €88 €170 Not stated Not stated

Buul et al

[61]

Not stated €28 Not stated €164 €50

Published Reviews

Yin and colleagues used a meta-analysis to compare bone scintigraphy, MRI and CT in

the detection of clinically suspected scaphoid fractures.[2] This is also the current

Cochrane review. The main results are shown in table 12.

Table 12: Results of a meta-analysis of the diagnostic properties of commonly used tests in

suspected scaphoid fracture.[2] (Ln DOR = Natural logarithm of Diagnostic Odds Ratio)

Imaging

modality

Number of

Studies

Number of

patients

Sensitivity [95%

CI]

Specificity

[95% CI]

Ln DOR [95%CI]

Bone

Scintigraphy

15 1,102 97% [93-995] 89% [83-94%] 4.78 [4.02-5.54]

MRI 10 513 96% [91-99%] 99% [96-100%] 6.60 [5.43-7.76]

CT 6 211 93% [83-98%] 99% [96-100%] 6.11 [4.56-7.66]

The studies included in the meta-analysis were generally small, with the largest recruiting

just over 200 patients. None of the studies were randomised. Bone scintigraphy

demonstrated a statistically worse specificity than MRI (p<0.001) and CT (p=0.001),

however there was no statistically significant difference between CT and MRI. The

diagnostic odds ratio (DOR) for MRI was greater than bone scintigraphy (p=0.009), but no

other significant differences were identified in DOR.

Ring and colleagues [60] also undertook a review of the literature and calculated the

diagnostic properties of bone scintigraphy, MRI, CT and ultrasound (Table 13). The high

negative predictive value is attributable to the low prevalence of scaphoid fractures.


Table 13: Diagnostic properties of commonly used imaging tests in suspected scaphoid

fracture.[60]

Imaging

modality

Number

of patients

Sensitivity

[95% CI]

Specificity

[95% CI]

Accuracy Prevalence

adjusted

positive

predictive

value

Prevalence

adjusted

negative

predictive

value

Bone

Scintigraphy

9 96% 89% 93% 0.39 0.99

MRI 22 98% 99% 96% 0.88 1.00

CT 8 94% 96% 98% 0.75 0.99

Ultrasound 4 93% 89% 92% 0.38 0.99

Overall, MRI appears to have the best diagnostic performance of the available second-

line imaging modalities, and has the additional advantage of detecting other wrist

pathology such as ligamentous injury. However, access to MRI is limited in many UK

hospitals and the test is contraindicated or poorly tolerated in some individuals. Given the

problems noted above in relation to bone scintigraphy, CT scanning is a reasonable

alternative if MRI is not possible or contraindicated.


7.3 Immobilisation

Published research in this area is very limited (see table 14), but the available evidence

suggests that a Scaphoid cast offers no benefit over a standard “Colles” cast, and is more

disabling for the patient. There may be some benefit to immobilising a Scaphoid fracture

in an above elbow cast, but the two studies in this area do not agree.

Table 14: Immobilisation

Study Patient Group Key Results

Kaneshiro et al [52] Cadaveric study of 4

iatrogenic scaphoid fractures

immobilised with a below

elbow cast

Significant movement of scaphoid

(>1mm) with

pronation/suppination

Clay et al [53] Prospective randomized trial

comparing rate of non-union

between patients randomly

allocated to either a “Colles”

or scaphoid cast. 292 patients

were reviewed at 2, 4 and 8

weeks when the cast was

removed. If healing was in

doubt at this point, the plaster

was replaced for a further 4

weeks.

No difference in non-union rate

between the two groups, but

patients felt the scaphoid cast was

more disabling.

Hambidge et al[56] Compared rate of non-union

after immobilising the wrist in

flexion or extension in fractures

of the waist or distal pole of

the scaphoid treated in a

“Colles” cast

No difference in non-union rate,

flexion or grip strength at 6 months,

but significantly reduced extension

in patients who were immobilized

in 20 degrees of flexion rather that

20 degrees of extension

Karantana et al [55] Compared hand function with

the wrist immobilized in a

“Colles” or scaphoid cast

Scaphoid cast caused significantly

more disability than the “Colles”

cast, or no cast at all

Gellman et al [57] Compared a long thumb

spica, which included elbow

immobilization (28 fractures),

with a short thumb spica that

did not immobilise the elbow

(23 fractures)

Fractures of the proximal or middle

third of the scaphoid healed

quicker if immobilised for 6 weeks

in a long thumb spica followed by

a short thumb spica, rather than

spending the entire period of

immobilisation in a short thumb

spica. Fractures of the distal third

healed independently of splint

length

Terkelsen et al [58] 48 patients in the long cast

group and 44 in the short cast

group, all of whom were

followed up for at least 12

months.

Non-union occurred in 2 of 5

fractures in the proximal part of

the scaphoid, and 8 of 77

fractures in the waist or distal part.

There were 7 non-unions in the

long cast group and 3 in the short

cast group, but this difference was

not significant (p=0.25).


7.4 Follow up

There is no useful evidence on the duration or timing of clinical follow-up in suspected

scaphoid fracture. Once a fracture has been confirmed or excluded further management

can proceed accordingly, and therefore clinical follow-up is only required until a firm

diagnosis has been made, either on clinical grounds or through the use of additional

imaging.

Outpatient review at two weeks is a popular option, based on the assumption that an

initially occult fracture will be more readily visualized on plain X-rays taken at this stage.

However, whilst it is true that scaphoid fractures that cannot be detected on initial X-rays

may become apparent on an X-ray taken after two weeks, the published evidence

indicates that scaphoid fractures may still be diagnosed for the first time when a patient is

X-rayed at 8 weeks,[29] though the clinical significance of such injuries is unclear.

7.5 Scaphoid fractures in children

These are rare fractures; accounting for 0.34% of all children’s fractures. However

scaphoid fractures become more common as the child grows older. [59]

Evenski and colleagues performed a retrospective review of children with suspected

scaphoid fracture who presented to a single children’s emergency department over a 7

year period.[24] Of 165 wrists, 104 were included in the study (there were 103 patients,

since in one child both wrists were included). 21 had scaphoid fractures on presentation,

11 had an ipsilateral upper limb fracture and there were incomplete data for 29. Those

included were 57 boys and 46 girls with an average age of 13 years (range 5-15 years).

31(30%) children were found to have a scaphoid fracture during follow up: 14 at two

weeks, 12 at five weeks and 5 at seven weeks.


8. Evidence-based flowchart

History compatible with possible fracture

AND

Examination confirms tenderness:

Anatomical snuffbox and/or scaphoid tubercle

Plain radiographs, scaphoid views

“Colles” cast and orthopaedic

follow-up

Immobilise in “Colles” cast or wrist splint

(according to local practice) until MRI

scan.

Thumb immobilisation is not required.

(Senior medical review may be useful to

exclude alternative causes of symptoms)

MRI scan

(CT scan if MRI contra-indicated)

Discharge:

no follow-up required

No Fracture

Fracture

Fracture

No Fracture


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